Athletic Staff Application

Registration Number for FBI Clearance

Statement or Letter of Interest

POSITION(S) DESIRED

First Name

Middle Name

Last Name

Present Address

Address Line 1

City

State

Zip Code

(Area Code) Telephone

Email Address

Date available for employment

Educational Background

High School

School Institution and Location

Degree and Major

Certification or License Held

College / University

School Institution and Location

Degree and Major

Certification or License Held

Coaching Experience

(Present or most recent first)

Name of Employer

Your Title

Employment Dates (From)

Employer Street Address

Name & Title of Supervisor

Employment Dates (To)

Employer City

Worked Performed

Final Yearly Salary

Employer State

Employer Zip Code

Employer (Area Code)Telephone

Reason for Leaving

Coaching Experience (cont'd)

Name of Employer

Your Title

Employment Dates (From)

Employer Street Address

Name & Title of Supervisor

Employment Dates (To)

Employer City

Worked Performed

Final Yearly Salary

Employer State

Employer Zip Code

Employer (Area Code)Telephone

Reason for Leaving

Coaching Experience (cont'd)

Name of Employer

Your Title

Employment Dates (From)

Employer Street Address

Name & Title of Supervisor

Employment Dates (To)

Employer City

Worked Performed

Final Yearly Salary

Employer State

Employer Zip Code

Employer (Area Code)Telephone

Reason for Leaving

References

Reference #1

Name

Street Address

(Area Code) Telephone

Position

City, State, and Zip Code

Email Address

Reference #2

Name

Street Address

(Area Code) Telephone

Position

City, State, and Zip Code

Email Address

Reference #3

Name

Street Address

(Area Code) Telephone

Position

City, State, and Zip Code

Email Address

Reference #4

Name

Street Address

(Area Code) Telephone

Position

City, State, and Zip Code

Email Address

Summarize special coaching related skills and qualifications acquired from employment or other experiences (including U.S. military service) and/or state any additional information you feel may be helpful in considering your application, i.e. honors, awards, activities, technology skills or professional development activities

GENERAL BACKGROUND INFORMATION

You must give complete answers to all questions. If you answer "Yes" to any question, you must list all offenses, and for each conviction provide date of conviction and disposition, regardless of the date or location of occurrence. Conviction of a criminal offense is not a bar to employment in all cases. Each case is considered on its merits. Your answers will be verified with appropriate police records. Criminal Offense includes felonies, misdemeanors, summary offenses and convictions resulting from a plea of "nolo contendere" (no contest). Conviction is an adjudication of guilt and includes determinations before a court, a district justice or a magistrate, which results in a fine, sentence or probation. You may omit: minor traffic violations, offenses committed before your 18th birthday which were adjudicated in juvenile court or under a Youth Offender Law, and any convictions which have been expunged by a court or for which you successfully completed an Accelerated Rehabilitative Disposition program.

Were you ever convicted of a criminal offense?

Yes

Are you currently under charges for a criminal offense?

Yes

Have you ever forfeited bond or collateral in connection with a criminal offense?

Yes

Within the last ten years, have you been fired from any job for any reason?

Yes

Within the last ten years, have you quit a job after being notified that you would be fired?

Yes

Are you subject to any visa or immigration status, which would prevent lawful employment?

Yes

Note: If you answered "Yes" to any of the above questions, please provide a detailed explanation on a separate sheet of paper, including dates, and attach it to this application. Please print and sign your name on the sheet, and include your social security number.

ACT 34 COMPLIANCE (Background Check of Prospective Employees) Each applicant must submit with the employment application a State and Federal criminal history report or a copy of the completed form/request.

ACT 151 (PA Child Abuse History Clearance) Each candidate must submit with his/her employment application a copy of an official clearance statement obtained from the Pennsylvania Department of Public Welfare or a statement from the Department of Public Welfare that no record exists. The clearance statement must be no more than one (1) year old. The applicant MUST submit the ORIGINAL report prior to employment. *******************************************

Certification and Release Authorization

I certify that all of the statements made by me are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I further certify that I am the sole author of the essay. I understand that any misrepresentation of information shall be sufficient cause for: (1) rejecting my candidacy, (2) withdrawing of any offer of employment, or (3) terminating my employment. I hereby authorize any and all of my previous employers and/or supervisors to release any and all of my personnel records, and to respond fully and completely to all questions that officials of Muncy School District may ask regarding my prior work history and performance. I will hold such previous employers and/or supervisors harmless of any and all claims that I might otherwise have against them with regard to statements made to this school district. I further authorize these officials to investigate my background, now or in the future, to verify the information provided and release from liability all persons and/or entities supplying information regarding my background. However, I do not authorize the production of medical records or other information, which would tend to actually identify a disability nor do I authorize inquiries which would include information related to any medical condition or medical history. Further, I do not waive any rights which I may have under state or federal law related to my right to challenge the disclosure of unlawful or inaccurate information, whether by the school district or by entities or persons providing such information to the school district, including any and all claims concerning allegations of employment discrimination because of race, color, sex, religion, national origin, ancestry, age or disability.

Yes

Full Name of Candidate providing CERTIFICATION AND RELEASE AUTHORIZATION

Date the Applicant is providing CERTIFICATION AND RELEASE AUTHORIZATION

Pennsylvania school districts shall not discriminate in their educational programs, activities or employment practices based on race, color, national origin, sex, disability, age, religion, ancestry or any other legally protected classification. This policy is in accordance with state and federal laws, including Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Sections 503 and 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act of 1990 and the Pennsylvania Human Relations Act. Information relative to special accommodation, grievance procedure, and the designated responsible official for compliance with Title VI, Title IX, and Section 504 may be obtained by contacting the school district.